prof ndr - parathyroid
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PROF.N.DORAIRAJANMS,FRCS(EDIN),FICS,FACS,FICA
PROFESSOR AND HEAD OF THE DEPARTMENTDEPARTMENT OF GENERAL SURGERY
MADRAS MEDICAL COLLEGE &
GOVT GENERAL HOSPITAL
CHENNAI
ENDOCRINE SURGEON APOLLO HOSPITALS, CHENNAI
PRESIDENT (2009-10)INTERNATIONAL COLLEGE OF
SURGEONSINDIAN SECTION
Asian federation secretaryINTERNATIONAL COLLEGE OFSURGEONSINTERNATIONAL SECTION
EDITORIAL BOARD MEMBERINTERNATIONAL SURGERY
CHAIRMANASI - TAMILNADU PONDICHERRY CHAPTER
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GROANS,MOANS
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56/M
C/o general body aches and pain over joints 1 month
H/o heartburns 2 monthsH/o nausea - 2 months
H/o anorexia - 2 months
No h/o hematemesis / melenaNo h/o vomiting
No h/o constipationNo h/o altered bladder habitsNo loss of weight and appetite
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Known diabetic 1 year
Underwent PTCA - 2006
Hypertension - 10 years
ESWL treatment for left renal calculus - 25 years ago.
Pt underwent upper GI endoscopy esophagitis
Pt developed anuria the same day
Admitted in nephrology department ,Apollo
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General examination clinically normal
PR- 82/mtBP 140/70 mmHg
CVS S1S2 +RS NVBS
P/A Soft , no mass felt , no organomegaly
Examination of neck clinically normal.
Examination of cranium / spine / pelvis / long bones clinically normal
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INVESTIGATIONS
Blood sugar 134 mg/dlblood urea 56 mg/dl
Serum creatinine 2.6 mg/dlSerum sodium 142 meq/dl
Serum potassium
4.9meq/dl
Serum calcium 17.8 g/dlSerum phosphrous 2.3 mg/dl
Serum magnesium
1.4 mg/dlUric acid 10.8 g
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Intact paratharmone 2140 pg /ml
Serum alkaline phosphatase 773 IU/dl
Renal doppler normal (left renal cortical cyst)
Serum protein electrophorosis normal
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Hypercalcemia unresponse to forced diuresis
Dialysis against a zero calcium bath.
Dialysis against a zero calcium bath.
Dialysis against a zero calcium bath.
HYPERCALCEMIA PERSIST
ENDOCRINOLOGIST OPINION
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ENDOCRINOLOGIST OPINION:
Advised :
Skeletal survey
USG neck
MIBI Parathyroid scan
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USG neck
A cystic nodule measuring 1.3cm seen in the leftlobe
Two large nodules are seen close to the lower poleof thyroid on either side measuring about 4 cm onright and 3 cm on left nodules show cystic areas
within.
Impression:
Large nodules with cystic changes close to thelower poles of thyroid glands suggestive of
parathyroid lesions
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99TC MIBI STATIC STUDYOF NECK / MEDIASTINUM
There is persistent tracer concentration noted in the midand the lower poles of both lobes of thyroid
Features suggestive of functioning parathyroid lesion in the
mid and lower poles of both lobes of thyroid
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DIAGNOSIS:
PRIMARY HYPERPARATHYROIDISM
? HYPERPLASIA? ADENOMA
PLAN:
PARATHYROIDECTOMY
STANDARD PARATHYROID SURGERYBILATERAL APPROACH
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PER-OPERATIVE DETAILS:
Right inferior parathyroid found enlarged
Left superior parathyroid also found enlargedLeft inferior parathyroid was enlarged with variable
consistencyLeft thyroid had multiple nodules.
Right superior parathyroid found normalRecurrent laryngeal nerve identified and preserved onboth sides
PROCEDURE :Subtotal parathyroidectomy and left hemithyroidectomy
Right inferior , left superior and inferior Parathyroidectomydone
Left hemithyroidectomy done.
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FROZEN SECTION:
Parathyroid adenoma
HPE REPORT:
Parathyroid : Parathyroid hyperplasia of all threeparathyroids
Thyroid : Nodular hyperplasia and focal lymphocyticthyroiditis
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POST OPERATIVE PERIOD:
Serum calcium 17.8 g/dl
Intact paratharmone
2140 pg /ml
Pre operative :
Sr.calcium Sr.Paratharmone
After 6 hrs 14.3 g/dl 422 pg/ml
After 12
hrs12.2 g/dl
After 24hrs 11.4 g/dl
After 48
hrs9.3 g/dl 223 pg/ml
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POST OPERATIVE PERIOD:
uneventful
Put on tab.calcium and tab.1,25 dihydroxyvitamin D dailyFrom 1st POD
A successful parathyroidectomy results in a decrease in serum calciumlevel ,which usually reaches its nadir 48 hrs after surgery.
A successful parathyroidectomy results in a decrease in serum PTH
level, > 50% in 5 minutes and > 60 % in 15 minutes
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POST OPERATIVE PERIOD:
On 7 th POD:
Blood sugar 134 mg/dlBlood urea 22 mg/dl
Serum creatinine 1.1 mg/dlSerum Na+ - 141 meq/lSerum K+ - 4.5 meq /l
Serum calcium
9.3 g/dlSerum phosphorus 3.3
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BONES
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FRACTURE NECK OF FEMUR
THIN CORTEX
POOR TRABECULAR PATTERN
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21/ F referred from Royapettah Govt Hospital
H/o accidental fall 3 months back.
Fracture left neck of femur.
H/o muscle and joint pain - 6 months.
H/o weakness on doing manual work - 6 months
No h/o nausea or heartburn.
No h/o loss of weight or appetite.
No h/o polyuria , polydipsia or constipation
Not known DM / HT / PTB
No h/o menstrual disturbances.
No h/o similar complaints in her family.
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General examination -shortening of left lowerlimb (
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INVESTIGATIONS
Biochemical investigations - Normal
LFT WNL
Alk.Phosp 128 IU/L
Serum calcium 13.9 mg/dl
Serum phosphorus 2.1 mg/dl
Serum intact paratharmone 1277 pg/ml
USG abdomen - normal
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USG neck
solitary right inferior parathyroid adenoma
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THIN CORTEX
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CT NECK PLAIN AND CONTRAST
28 X 11 X 11 MM isodense soft tissue lesion showing
intense enhancement with contrast noted in the region of
right paratreacheal ,inferior and posterior to the right
lobe of thyroid
Features suggestive of parathyroid adenoma
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Tc 99m Sestamibi scan study shows an areaof tracer retention corresponding to the
region of right lower pole of thyroid gland
Scan finding concordant with USGfindings of Parathyroid adenoma.
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DIAGNOSIS :
PRIMARY HYPERPARATHYROIDISM
RIGHT LOWER PARATHYROID ADENOMA
PLAN :
RIGHT LOWER PARATHYROIDECTOMY
MINIMAL INVASIVE PARATHYROID SURGERY
UNILATERAL APPROACH
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HEAD
NECK
CHEST
INFERIOR POLE RT THYROID
RT PARATHYROID ADENOMA
RT STERNOCLEDIOMASTOID
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HEAD
NECK
INFERIOR POLE RT THYROID
SPACE AFTER REMOVAL OF PARATHYROID ADENOMA
RT STERNOCLEDIOMASTOID
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POST OPERATIVE PERIOD:
SERUMCALCIUM
(g/dl)
Pre
operative
13 .9
Post
operative (6
hrs)
11.3
SERUM
PTH(pg/m
l)
1277 16
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POST OPERATIVE PERIOD:
uneventful
Administred with tab.calcium andtab.1,25 dihydroxyvitamin D daily.
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BONE MINERAL DENSITY
TOTAL BODY BONE MINERAL DENSITY OF 0.635 G /CM3 ,
CORRESPONDING TO A T - SCORE OF 4.4
AP SPINE L1 L4 MEAN DENSITY OF 0.425 G /CM3 ,
CORRESPONDING TO A T - SCORE OF
6.2RIGHT FEMUR MEAN DENSITY OF 0.257 G /CM3 ,
CORRESPONDING TO A T - SCORE OF 6.2
LEFT ORTHO FEMUR MEAN DENSITY OF 0.295 G /CM3
SUGGESTIVE OF OSTEOPOROSIS , FRACTURE RISK HIGH
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STONES
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28 / F referred from Urology department
C/o pain left loin 3 months
No h/o hematuria
H/o muscle and joint pain - 6 months.
H/o weakness on doing manual work - 4 months.
No h/o nausea or heartburn.
No h/o loss of weight or appetite.
No h/o polyuria , polydipsia or constipation
Not known DM / HT / PTB
No h/o menstrual disturbances.
No h/o similar complaints in her family.
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Past history of passing calculus during micturation
5yrs agoESWL treatment for left renal calculus - 4 years ago
Not known DM / HT / PTB
No h/o menstrual disturbances.
No h/o similar complaints in her family.
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General examination clinically normal
PR- 82/mtBP 120/70 mmHg
CVS S1S2 +RS NVBS
P/A Soft , no mass felt , no organomegaly
Examination of neck clinically normal.
Examination of cranium / spine / pelvis / long bones clinically normal
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INVESTIGATIONS
Biochemical profile - NormalX-Ray KUB multiple renal calculus both left and right side
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USG ABDOMEN : multiple left renal calculus
calculus measuring 6 x 5mm in right
pelvic ureteric junction
bladder normal
Serum Calcium 14.2 g/dlSerum Phosphorus 2 g/dl
Intact paratharmone - 945 pg/ml
Sketetal survery - normal
PARATHYROID SCAN
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There is persistent tracer concentration noted in the
lower poles of right lobe of thyroid
Features suggestive of parathyroid lesion in the
lower poles of right lobe of thyroid
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DIAGNOSIS:
PRIMARY HYPERPARATHYROIDISM
ADENOMA
PLAN :
RIGHT LOWER PARATHYROIDECTOMY
MINIMAL INVASIVE PARATHYROID SURGERYUNILATERAL APPROACH
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POST OPERATIVE PERIOD
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POST OPERATIVE PERIOD:
Per operative serum calcium 14.2 g/dl
Peropaerative serum Paratharmone 945 pg/mlSr. Calcium Sr .Paratharmone
After 6 hrs 11.5 g/dl 180 pg/ml
After 24
hrs10.6 g/dl
After 48hrs 9.3 g/dl 70 pg/ml
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POST OPERATIVE PERIOD:
uneventful
Administred with tab.calcium andtab.1,25 dihydroxyvitamin D daily.
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PRIMARY HYPERPARATHYROIDISM
HYPERPLASIA HYPERPLASIA ADENOMA
RENAL CALCULUS
RENAL FAILURE PATHOLOGICAL
FRACTURES
HOW HYPERPARATHYROIDISM PRESENTS ?
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Tired all the time.
Feel old. Depression. Osteoporosis and Osteopenia.fractures Gastric acid reflux; heartburn; GERD. Decrease in sex drive. Thinning hair (predominately in older females).
Kidney Stones. High Blood Pressure Recurrent Headaches (usually patients under the age of 40). Heart Palpitations (arrhythmias). Typically atrial arrhythmias.
Most people with hyperparathyroidism will have 4 - 6 of these symptoms
In general, the longer you have hyperparathyroidism, the more symptoms youwill develop.
HOW HY E HY O D SM ESEN S ?
Copyright 1996-2008 Norman Endocrine Surgery Clinic
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People with calcium levels of 10 or 11 have just as many symptoms as people with
calcium levels of 12 or 13.
People with higher calcium levels do NOT have more symptoms.
Norman Parathyroid clinic
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In patients who have Serum Calcium levelsthat are only slightly elevated, or they areelevated and the PTH levels are borderlinehigh, THEN, the measurement of Ionized
Calcium becomes important.
Remember
It is NEVER normal to have a high calcium level.
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Diagnosis of PHPT is made by metabolic testing
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Diagnosis of PHPT is made by metabolic testing
Elevated serum calcium
Elevated ionised calcium
Elevated intact PTHLow or normal blood phosphorus
Increased chloridephosphorus ratio ( > 33 )
Increased uric acid
Elevated alkaline phosphataseParathyroid harmone related peptide (PTHrP) - Most common
peptide secreted by Nonparathyroid cancers.
The intact PTH assays do not cross react with Parathyroid harmone
related peptide (PTHrP)
Documentation of serum creatinine,blood urea nitrogen and
serum protein electrophoresis - To rule out Multiple myeloma
Study Type Sensitivity Specificity
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Study Type Sensitivity Specificity
Ultrasound 71-80% 80%
EndoscopicUltrasound 71%
CT Scan 46-80% 88-98%
MRI Scan 64-78% 88-95%
Thallium-TechnetiumScan
75% 73-82%
Technetium-SestamibiScan
90.7% 98.8%
PET Scan 80-94%
Angiography & Venous
Sampling91-95% 96-98%
Venous SamplingAlone 70-80%
Parathyroid localisation - current practice
B. DIJKSTRA, C. HEALY, L.M. KELLY, E.W. MCDERMOTT, A.D.K. HILL and N.OHIGGINS
Department of Surgery, St Vincents University Hospital, Elm Park, Dublin 4, Ireland
L li i f id if h i b d k h
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Localization tests often identify the tumor site but do not make the
diagnosis because both false positive and false negative localization
tests occur.
SPECT (Single Proton Emission Computerized Tomography)
SPECT scanning is a variant of Sestamibi Scanning for parathyroid glands.
increase the accuracy of routine Sestamibi scanning by about 2 to 3 percent.The most important use for SPECT scanning is when ordinary Sestamibi scans areinconclusive or when a more detailed anatomic localization is necessary such as when
patients are being re-operated on.
MRI Scans
Are valuable very rarely (almost never) because MRI scans don't show
parathyroid tumors.
At best, an MRI will find less than 8% of parathyroid tumors
ROLE OF FNAC
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ROLE OF FNAC
Diagnostic aspiration of parathyroid adenomas causes
severe fibrosis complicating surgery and final histologic diagnosis.Norman J, Politz D, Browarsky I.Norman Endocrine Surgery Clinic, Tampa, Florida 33613, USA.
FNA of parathyroid adenomas can cause a severe fibrotic process that
typically involves adjacent tissues. This reaction dramatically increases t
difficulty of surgical resection, often requiring microdissection techniquto preserve nerves and assure complete removal.
The fibrosis can cause confusing histology mimicking malignancy.
FNA of parathyroid adenomas should be avoided unless absolutely
necessary.
Thyroid. 2007 Dec;17(12):1251-5
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PRIMARY HYPERPARARTHYROIDISM
SURGICAL MANAGEMENT
WHY ???
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EFFECT OF SURGICAL TREATMENT
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EFFECT OF SURGICAL TREATMENT
Normocalcemia is achieved by surgery in 95% and maintained for
years.
Risk of complication is small and mortality is rare
Response of symptoms to Parathyroid surgery
SYMPTOMS
LONG TERM
IMPROVEMENT(%)
Renal stones 90
Osteitis fibrosa 100
Hypertension 3
Malaise , fatigue 78
Abdominal pains 63
Vague pains in extremities 51
depression 65
INDICATIONS FOR SURGERY IN PATIENTS WITH
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ASYMPTOMATIC
PRIMARY HYPERPARATHYROIDISM
CONDITION SURGERY
AGEYoung
old
Always
If additional indications
SERUM CALCIUM>3.0 mmol
2.85 3.0
10 mmol/24 h Usually
RENAL FUNCTIONimpaired Usually
General principles for surgical exploration inP i h h idi
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Primary hyperparathyroidism
Keep the surgical field bloodless , so as to prevent discoloring of
Parathyroid glands.
Parathyroid Light brown
Fat Yellow
Lymphnodes Grey
Cryopreserve parathyroid tissue for subtotalParathyroidectomy and for all reoperations.
The risk of post operative hypoparathyroidism is increased if all
normal Parathyroid glands are biopsied routinely,so routine biopsy
of all normal Parathyroid glands should be discouraged.
WHERE TO FIND THE
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WHERE TO FIND THE
INFERIOR PARATHYROID GLANDS ?
The inferior parathyroid glands and thymus develops from
the third branchial pouch.
The most common position of the inferior parathyroid gland
is anteroinferior to the junction of the Inferior thyroid
artery and the recurrent laryngeal nerve
WHERE TO FIND THE
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WHERE TO FIND THE
SUPERIOR PARATHYROID GLANDS ?
The superior parathyroid glands develops from the fourth
branchial pouch.
Most common location of the superior gland is just superoposterior
to the junction of the inferior thyroid artery and the recurrent
laryngeal nerve at the level of cricoid cartilage.
The superior parathyroid is frequently found in thetracheoesophageal groove posteriorly and may descend along
the esophagus into the posterior mediastinum
TROUBLE SHOOTING FOR MISSING
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TROUBLE SHOOTING FOR MISSING
PARATHYROID GLANDS
Right lower parathyroid gland cannot be localized:
The thymus on the side should be
exposed.
The retrosternal part of the thymus is
mobilised
Consider possibility of intrathyroidal parathyroid
TROUBLE SHOOTING FOR MISSING
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TROUBLE SHOOTING FOR MISSING
PARATHYROID GLANDS
Right upper parathyroid gland cannot be localized.:
Space dorsal to the thyroid gland and theesophagotracheal groove should be
explored.
Space between the esophagus and thevertebrae should be opened.
TROUBLE SHOOTING FOR MISSING
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TROUBLE SHOOTING FOR MISSING
PARATHYROID GLANDS
Four normal parathyroids have been visualised.
Increased levels of parathyroid harmone:
Rule out another cause of hypercalcemia.Can be due to tumor orginating from a
supernumerary parathyroid gland located
in the thymus.
Resection of the left and right thymus
is indicated.
R BLE H NG F R NG
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TROUBLE SHOOTING FOR MISSING
PARATHYROID GLANDS
Left lower parathyroid gland is missing:
At the level of the superior thyroid arteryand anterior to the carotid bulb,an enlarged
parathyroid gland with a thymic remnant is
encountered.
A maldescended fourth pharyngeal pouch
is likely,resulting in a cranial position of the
upper Parathyroid gland.
SURGERIES FOR PARATHYROID
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SURGERIES FOR PARATHYROID
OPEN ENDOSCOPIC
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Identify which patients have only one abnormalparathyroid BEFORE the
operation, not during it!
Know with a very high degree of accuracy WHEREthe tumor is located
BEFORE the operation so you don't have to dissectall of the neck structures
trying to find it.
UN L TER L VER U B L TER L PPRO CH
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UNILATERAL VERSUS BILATERAL APPROACH
UNILATERAL APPROACH:
Post operative hypocalcemia will be reduced.
Early ambulation can be achieved - reducing the total cost
for the surgery.
Non explored side the parathyroid glands are ready to start
functioning immeditely after the removal of the adenoma
The mere exploration of the contralateral side without
removing any parathyroid tissue will increase post operative
hypocalcemia.
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Carries low risk of nerve complication
Reduced time of surgery
For patients with severe respiratory or cardiovascular
disease and an increased surgical risk,Unilateral exploration
under local anasthesia is a useful method of treatment.
DISADVANTAGES:
Missing of Supernumerary glands and Double adenomas.
ll
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Follow up:
In patients with parathyroid hyperplasia
annual serum calcium determination
In patients with adenoma
every 5th year serum calcium determination
Measurement of other biochemical parameters -unnecessary if Preoperative renal function
is normal.
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1. Symptoms of parathyroid disease do NOT correlate with thelevel of calcium in the blood.
2. Fluctuating levels of calcium are typical of parathyroiddisease.
3. All patients with hyperparathyroidism will developosteoporosis.
4. As a rule Parathyroid disease will worse with passage of time
5. There is only one treatment for parathyroid disease(hyperparathyroidism): Surgery
6. Nearly all parathyroid patients can be curedwith aminimaloperation.
7. The success rate and complication rate for parathyroidsurgery is VERY dependent upon the surgeons experience.
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THANK YOU
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